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Anderson et al. recently published an excellent comprehensive review on chest tube management (Anderson 2022). But they omitted a key essential step ensuring that the chest tube will be inserted on the correct side. In the early 1990s, wrong-side chest tube insertion was one of the leading wrong site procedures in our New York Patient Occurrence Reporting and Tracking System (NYPORTS). Failure to perform the same sort of timeout and verification process that we use in the OR is a major reason that we still see wrong-side chest tube insertions.
In our July 2014 What's New in the Patient Safety World column Wrong-Sided Thoracenteses we noted some factors identified from wrong-side thoracenteses that would likely also contribute to wrong-side chest tube insertions. Miller et al. (Miller 2014) reported on 14 cases of thoracenteses performed on the wrong side outside the OR setting. A resident performed the procedure in 10 of the cases and an attending performed 2. An attending was present in 6 cases and a nurse was present in just 3 cases.
The most frequent associated factor was failure to perform a timeout (12 of the 14 cases). Laterality was missing from the consent form in 10 cases and the site was not marked in 12 cases. Medical image verification was not done in 7 of the 10 cases where information was available.
They found 30 root causes in the 14 cases (average 2.1 root causes per event). These most often included communication issues, failure to follow policy or procedures, and equipment issues. In several cases, the images were not available at the time of the procedure. That is particularly problematic in todays computerized environment. If the PACS system is down, you may not have immediate access to the images. In the old days wed bring the actual films with us to the bedside. Today there are no films, only the images on the computer system.
The authors also note that right-left confusion is a common human error in many scenarios. They note one resident knew the pleural effusion was on the left side on the x-ray but when he went behind the patient the x-ray image in his mind reversed.
Miller et al. note a number of strategies that are helpful in preventing such events. First is formal standardization of Universal Protocol and timeouts for invasive procedures anywhere, not just in the OR. Checklists, site marking, and ultrasound localization are also useful. Learning and practicing the procedures in a simulation environment is also encouraged. Development of a culture of patient safety and good communication is also critical.
While education, training, and simulation are all important, our own approach would incorporate forcing functions or constraints, which are much more effective interventions in most solutions. There are two good ways to ensure that a timeout gets done and force all the appropriate elements to prevent a wrong-site, wrong-side, or wrong-patient procedure. One is to prevent a physician from accessing the procedure tray all alone. That is best done by requiring an order for the tray, which would require a nurse to access the tray and accompany the physician to the patients room (or other site where the procedure will be performed) and participate in the timeout and the procedure. Second is to include on the outside of the sterile procedure tray a checklist that must be completed prior to opening the sterile tray. That checklist, of course, would include the items typically in the Universal Protocol and timeouts (things like consent, verification of the patient, procedure, laterality including review of relevant imaging studies, etc.).
That approach is borne out by another study (Barsuk 2011) that looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities (see our June 6, 2011 Patient Safety Tip of the Week Timeouts Outside the OR). Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurses alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process.
Good chest tube management includes all the elements elegantly outlined by Anderson et al., but also begins by including these important steps prior to breaking the seal on the procedure kit.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 Checklists and Wrong Site Surgery
June 5, 2007 Patient Safety in Ambulatory Surgery
July 2007 Pennsylvania PSA: Preventing Wrong-Site Surgery
March 11, 2008 Lessons from Ophthalmology
July 1, 2008 WHOs New Surgical Safety Checklist
January 20, 2009 The WHO Surgical Safety Checklist Delivers the Outcomes
September 14, 2010 Wrong-Site Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site Neurosurgery
January 19, 2010 Timeouts and Safe Surgery
June 8, 2010 Surgical Safety Checklist for Cataract Surgery
December 6, 2010 More Tips to Prevent Wrong-Site Surgery
June 6, 2011 Timeouts Outside the OR
August 2011 New Wrong-Site Surgery Resources
December 2011 Novel Technique to Prevent Wrong Level Spine Surgery
October 30, 2012 Surgical Scheduling Errors
January 2013 How Frequent are Surgical Never Events?
January 1, 2013 Dont Throw Away Those View Boxes Yet
August 27, 2013 Lessons on Wrong-Site Surgery
September 10, 2013 Informed Consent and Wrong-Site Surgery
July 2014 Wrong-Sided Thoracenteses
March 15, 2016 Dental Patient Safety
May 17, 2016 Patient Safety Issues in Cataract Surgery
July 19, 2016 Infants and Wrong Site Surgery
September 13, 2016 Vanderbilts Electronic Procedural Timeout
May 2, 2017 Anatomy of a Wrong Procedure
June 2017 Another Way to Verify Checklist Compliance
March 26, 2019 Patient Misidentification
May 14, 2019 Wrong-Site Surgery and Difficult-to-Mark Sites
May 2020 Poor Timeout Compliance: Ring a Bell?
September 14, 2021 Wrong Eye Injections
October 5, 2021 Wrong Side Again
November 9, 2021 Ensuring Safe Site Surgery
Anderson D, Chen SA, Godoy LA, et al. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg 2022; Published online January 26, 2022
Miller KE, Mims M, Paull DE, et al. Wrong-Side Thoracentesis: Lessons Learned From Root Cause Analysis. JAMA Surg. 2014; 149(8): 774-779
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 941-954
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